T2 Ankle Arthrodesis Nail - Stryker

T2 

Ankle Arthrodesis Nail 

Operative Technique 

1

Ankle Arthrodesis Nailing System 

Contributing Surgeons 

Joseph D. DiCicco D.O. 

Chief Orthopedic Trauma 

Good Samaritan Hospital 

Chairman, Dept of Orthopaedic Surgery 

Grandview Hospital, Dayton, Ohio 

Clinical Professor Orthopaedic Surgery 

Ohio University & Wright State University 

Dayton, Ohio 

Thomas Mückley, M.D. 

Department of Trauma, Hand and 

Reconstructive Surgery 

University Hospital Jena 

Germany 

Anthony T. Sorkin, M.D. 

Rockford Orthopaedic Associates, LLP 

Clinical Instructor, Department of Surgery 

University of Illinois, College of Medicine 

Director, Orthopaedic Traumatology 

Rockford Memorial Hospital 

Rockford, Illinois, USA 

This publication sets forth detailed 

recommended procedures for using 

Stryker Osteosynthesis devices and 

instruments. 

It offers guidance that you should 

heed, but, as with any such technical 

guide, each surgeon must consider 

the particular needs of each patient 

and make appropriate adjustments 

when and as required. A workshop 

training is required prior to first 

surgery. 

See package insert (L22000007) for 

a complete list of potential adverse 

effects, contraindications, warnings 

and precautions. The surgeon must 

discuss all relevant risks, including the 

finite lifetime of the device, with the 

patient, when necessary. 

2 

Warning: 

All bone screws referenced in 

this document here are not 

approved for screw attachment or 

fixation to the posterior elements 

(pedicles) of the cervical, thoracic 

or lumbar spine.

Contents 

Page 

1. Introduction 4 

Implant Features 4 

Design Rational 4 

Technical Details 5 

Instrument Features 6 

2. Relative Indications & Contraindications 7 

3. Pre-operative Planning 7 

4. Locking Options 7 

5. Operative Technique 8 

Patient Positioning and Joint Surface Preparation 8 

Incision and Entry Point 9 

Reaming 11 

Target Device Assembly 12 

Nail Insertion 13 

Guided Locking via Targeting Device 14 

Approsition/Compression Locking Mode 14 

Static Locking Mode 20 

Freehand Proximal Locking of Long Nails 23 

End Cap Insertion 24 

Nail Removal 25 

Case Resport 26 

References 27 

Ordering Information – Implants 28 

Ordering Information – Instruments 29 

3

Introduction 

Introduction 

The T2 Nailing System represents 

Stryker´s latest and most 

comprehensive development of the 

original intramedullary principles 

presented by Prof. Gerhard Küntscher 

in 1940. With a new generation of 

T2 Nails (e.g. T2 Proximal Humeral 

Nail, T2 Supracondylar Nail, T2 

Recon Nail), the indications have 

extended from shaft fractures to 

fractures of the metaphyseal regions. 

In addition to the T2 Nailing systems 

for Femoral, Tibial, and Humeral 

fractures, Stryker Osteosynthesis has 

developed the T2 Knee Arthrodesis 

Nail and, more recently, the T2 Ankle 

Arthrodesis Nail to provide the 

option for tibiotalocalcaneal fusion 

with a retrograde intramedullary nail. 

The main advantages of the technique 

are limited soft tissue damage in the 

ankle area, high primary stability 

allowing early weight bearing, 

(3) as well as compression of the 

subtalar and tibiotalar joints (5). 

Severe arthrosis and deformity 

of the ankle and subtalar joints 

are debilitating problems that 

can be difficult to treat. The 

tibiotalocalcaneal fusion with a 

retrograde intramedullary nail can 

be considered a salvage procedure 

for severe arthrosis and deformity 

of the ankle and subtalar joints (1). 

Ankle arthrodesis is a challenging 

procedure due to poor host conditions 

(e.g. bad skin, deformity, avascular 

necrosis), inability to get adequate 

fixation for this slow healing process, 

and the inability to get adequate 

compression across the fusion. 

Like other nails in the T2 family, 

the T2 Ankle Arthrodesis Nail 

enables the surgeon to create an 

inherently stable construct by 

providing internal compression to 

the fusion mass and distal crosslock 

holes within the nail to generate an 

intramedullary fixed-angle device. 

Performing an ankle arthrodesis can 

be technically demanding because of 

the shape and small size of the talus. 

Therefore, preoperative planning is 

an absolute necessity to determine 

placement and number of screws (2). 

The T2 Ankle Arthrodesis Nailing 

System is based on the established 

T2 instrument platform and locking 

screws. It offers the advantages of a 

unique locking configuration allowing 

for tibiotalocalcaneal fixation. 

Implant Features 

The T2 Ankle Arthrodesis Nail offers 

strong biomechanical* intramedullary 

stabilization using cannulated 

implants for the tibiotalocalcaneal 

fusion. 

All implants of the T2 Ankle 

Arthrodesis Nailing System are 

made of Type II anodized titanium 

alloy (Ti6Al4V) for enhanced 

biomechanical and biomedical 

performance*. 

Standard 5mm cortical screws 

simplify the surgical procedure and 

offer the advantages of both reduced 

insertion torque and low profile 

heads*. Fully Threaded Locking 

Screws are available for standard 

locking procedures. Partially 

Threaded Locking Screws (Shaft 

Screws) are designed for use if 

apposition/compression is applied. 

The proximal locking configuration 

features a round and an oblong hole to 

allow for static or dynamic locking. 

Controlled apposition/compression 

up to 5mm can be applied at the 

tibio-talar joint by introducing a 

Compression Screw from the driving 

end of the nail against the 5mm 

Shaft Screw placed in the talus. The 

Compression Screw is cannulated 

therefore allowing nail insertion over 

the guide-wire with the compression 

screw pre-loaded. 

T2 Ankle Arthrodesis Nails come in 

10, 11 and 12mm diameters and 150, 

200 and 300mm lengths. The driving 

end diameter is 12mm for all nails. 

* Data on file at Stryker: 

- Test Report No 130505CG1 Strength calculation 

(FEA) of 10mm T2 Ankle Arthrodesis Nail 

- White Paper: Ti6Al4V with Anodization Type II 

Biological Behavior and Biomechanical Effects 

Axel Baumann, Dipl.-Ing. DOT GmbH, Rostock, 

Germany, Nils Zander, Dipl.-Ing. Stryker 

Trauma GmbH, Schönkirchen / Kiel, Germany 

- Test Report 080103HK1 T2 / S2: Modified screw 

head design of cross screws Ø4 / 5mm 

Design Rationale 

The design of the T2 Ankle 

Arthrodesis Nail features a 5° 

lateral (valgus) bend providing an 

anatomical fit with better purchase 

through the calacaneal bone. 

Proximal locking is performed 

from medial to lateral in order to: 

• Avoid damage of muscular and 

neuro-vascular stuctures located 

on the lateral side of the tibia 

• Avoid interference with the fibula. 

The low profile design of T2 

Locking Screws helps reduce 

prominence under the soft tissue 

on the medial cortex of the tibia. 

Two 5mm Fully Threaded Locking 

Screws can be placed in the 

calcaneus: the proximal one in a 

L/M direction through a threaded 

locking hole, and the distal one in 

P/A direction with a 10° angle from 

postero-medial to antero-lateral 

(Fig. 1). This design dictates the 

need for left and right nails. 

Internal compression techniques are 

preferred because of higher union 

rates, shorter fusion times, and fewer 

complications (2). 

End Caps in different sizes are 

available to provide the improved 

fit for every indication and lock 

down on the PA calcaneal screw. 

This feature creates a fixed angle 

between the nail and Locking 

Screw. 

See the detailed chart on the next 

page for the design specifications 

and size offerings of the implants. 

4

Features 

Technical Details - T2 Ankle Arthrodesis Nail 

Diameter 

Sizes 

10, 11 and 12mm 

(Left and Right) 

150, 200 and 300mm 

Note: 

Driving end diameter is 12mm 

for all nails. 

40mm 

15mm 

5mm 

5.0mm Partially Threaded 

Locking Screws (Shaft Screws) 

L=25mm – 120mm 

Note: 

Screw length is measured 

from top of head to tip. 

lateral 

Compression Screw 

medial 

5mm 

5.0mm Fully Threaded 

Locking Screws 

L=25mm – 120mm 

47mm 

19.5mm 

7.5mm 

Endcap 

anterior 

10° 

Compression Screw 

(cannulated) 

lateral 

medial 

End Caps 

Standard +5mm +10mm +15mm 

Fig 1 

View from distal 

5

Features 

Instrument Features 

The major advantage of the 

instrument system is the integration 

of a core instrument platform 

which can be used not only for the 

complete T2 Nailing System, but 

also represent the platform for all 

future Stryker Osteosynthesis nailing 

and further reduces complexity 

and inventory. The T2 instrument 

platform offers advanced precision 

and usability, as well as ergonomically 

styled targeting devices. Except 

for the addition of a small number 

of dedicated instruments, the T2 

Femoral Instrument platform is used 

for the T2 Ankle Arthrodesis Nail. 

Targeting Device 

Apposition Ring 

Apposition Sleeve 

Dedicated instruments for the 

T2 Ankle Arthrodesis Nail 

include the Ankle Arthrodesis 

Targeting Device and a special 

Compression Screwdriver. 

Apposition Handle 

A pre-assembled Apposition Handle 

and Ring/Sleeve allow for applying 

additional external compression. 

As with all T2 Nailing Systems, the T2 

Ankle Arthrodesis Targeting Device 

is made of carbon fiber and features 

a friction locking mechanism to lock 

the Tissue Protection Sleeves in place. 

Both proximal and distal holes of 

the 150mm and 200mm nails can be 

locked with the Targeting Device. For 

proximal locking of the 300mm nails, 

free hand technique must be applied. 

An additional Aiming Adapter can 

be attached to the Targeting Device 

to help achieve the appropriate 

rotation based on the position of 

the PA calcaneal screw aligned with 

the anatomic calcaneal body axis. 

Aiming Adapter 

6

Relative Indications & Contraindications 

Relative 

Indications and 

Contraindications 

The T2 Ankle Arthrodesis Nail 

may be used for: 

• Posttraumatic and primary 

Arthrosis 

• Neuromuscular deformity 

• Revision of Failed Ankle 

Arthrodesis 

• Failed Total Ankle Replacement 

• Avascular Necrosis of the 

Talus (requiring tibiocalcaneal 

arthrodesis) 

• Neuroarthropathy (Charcot) 

• Rheumatoid Arthritis with severe 

deformity 

• Osteoarthritis 

• Pseudarthrosis 

The T2 Ankle Arthrodesis Nail should 

NOT be used if following conditions 

are present: 

• Tibial malalignment of > 10˚ in 

any plane 

• Severe vascular deficiency 

• Osteomyelitis or soft tissue 

infection 

Pre-operative 

Planning 

Preoperative clinical and radiological 

assessments are very important for the 

surgical outcome. 

• Clinical assessment comprises: 

evaluation of pain, quality and 

viability of soft tissue at the 

surgical site, neurological and 

vascular status. 

• Radiological assessment of the 

ankle includes: weight bearing 

anteroposterior and lateral views. 

A lateral hindfoot and Broden’s 

view are useful in evaluating the 

subtalar and transverse tarsal 

joints. 

• Appropriate implant size can be 

selected with the T2 Ankle X-Ray 

Template (1806-3217). 

Locking Options 

Based on the clinical and radiological 

assessment, different locking 

options can be used to obtain 

the Tibiotalocalcaneal fusion: 

Apposition/Compression 

Locking Mode: 

- Tibio-talo internal compression 

with or without additional talocalcaneal 

external compression 

(static locking proximal) 

- Tibio-talo-calcaneal external 

compression (static locking 

proximal and distal) 

Static Locking Mode: 

- Talo-calcaneal static locking 

with proximal static locking 

Dynamic Locking Mode: 

- The proximal oblong hole allows 

for secondary dynamization 

Note: 

Please see package insert for 

warnings, precautions, adverse 

effects and other essential product 

information. 

7


Patient Positioning and Joint Surface Preparation 

Positioning 

Place the patient supine on a 

radiolucent table (Fig. 2). Care should 

be taken to assure neutral alignment 

of the knee and ankle. Prepare the 

entire foot and ankle and drape 

the limb free from above the knee 

to allow intraoperative assessment 

of lower limb alignment to avoid 

malalignment later in the procedure. 

The lower limbs should hang over the 

operating table about 15−20cm and 

the affected limb should be elevated 

by placing a bolster under the calf. 

This position will allow: 

- Easy exposure to the C-Arm 

for the X-Ray control 

- Proximal locking from medial side 

and distal locking from lateral side 

- Convenient access for posterior 

locking of the PA calcaneal screw. 

Fig 2 

Place the C-Arm on the opposite 

side and make sure that both lateral 

and anterioposterior views of the 

lower limb can be obtained. 

Exposure 

Make a 5−6 cm lateral incision in 

line with the distal lateral malleolus. 

To gain access to the tibiotalar joint, 

resection of the most distal portion 

of the fibula just above the tibiotalar 

joint might be required (Fig. 3). 

This allows adequate exposure 

of the tibiotalar joint and may 

provide source of bone graft 

if required. Resect the distal 

fibula at an angle superolateral 

to inferomedial to prevent 

prominence after healing (Fig. 4). 

Fig 3 

Any exposure (lateral or medial) may 

be used as long as it allows adequate 

access to the tibiotalar and subtalar 

joints. In complex cases, exposure 

of both sides might be required. 

Fig 4 

8


Joint Preparation 

Correction of any deformity should 

be addressed at this time. Generally, 

the contours of the tibiotalar and 

subtalar joints are maintained with 

denuding of any articular cartilage. 

Sometimes a “flat on flat” surface 

can be used depending on surgeon 

preference. Tibiotalar joint 

preparation may be aided by a 

laminar spreader or distraction of 

some kind. Care should be taken 

to avoid excessive bony resection 

which may later result in limb 

shortening or loss of talar fixation. 

Ankle positioning for fusion 

Several authors have attempted 

to define the optimal position for 

ankle arthrodesis without objective 

multiplanar radiographic analysis 

and consistent reference points (4). 

Position the foot with neutral ankle 

dorsi-plantar flexion, 5−10˚ external 

rotation in relation to the tibial crest 

and 5˚ of hindfoot valgus seems to be 

the most accepted 

(Fig. 5). An assistant should 

maintain this position for proper 

entry point determination. 

Incision and Entry Point 

Incision: 

After joint preparation and 

confirmatory X-Ray evaluation 

of fusion position, the incision 

point is determined as follows: 

Place a K-Wire (1806-0050S) on the 

plantar surface (1/3 lateral) and take 

an axial heel view to align it with 

the longitudinal axis of the calcaneus 

(Fig. 6). Mark this line with a pen on 

the skin. Next, place the K-Wire on 

the lateral side of the ankle aligning 

the wire along the tibial axis on a 

lateral fluoroscopic view. Mark this 

line with a pen on the skin extending 

the line onto the plantar surface 

(Fig. 7). 

The starting point for the incision 

is determined by the intersection of 

the two lines on the plantar surface. 

The line marked on the plantar 

surface which is aligned with the 

longitudinal axis of the calcaneus 

will also help align the Aiming 

Adapter after Nail insertion. 

A longitudinal incision approximately 

2−3cm should be made at this 

intersection. Careful dissection is 

then utilized to gain access to the 

plantar surface of calcaneus. 

Fig 6 

5° – 10° 

Fig 7 

Fig 5 

5° 

9


Entry Point 

The entry point is made under 

lateral and axial heel fluoroscopy 

control (Fig. 8) by using one of the 

following options: 

- A center-tipped Drill 

Ø4.2×340mm (1806-4260S). 

- A Stepped Reamer, Ø8/12mm 

(1806-2013), over a Ø3×285mm 

(1806-0050) K-Wire. 

The Wire should be inserted to 

the level of the superior aspect of 

the talar cut or prepared surface. 

Once this position has been verified 

as center/center in the talus, the 

Stepped reamer is inserted over the 

wire. 

It is recommended in this case to 

use the Protection Sleeve Retrograde 

(703165). 

Note: 

Do not use bent K-Wires. 

The axial heel view can help center 

and assure good position within the 

calcaneal body. 

Stop the Drill or Stepped Reamer 

after passing through the tibial 

articular surface gaining access into 

the tibial canal. 

Fig 8 

10


Reaming 

Insert the Ø3×800mm Ball Tipped 

Guide Wire (1806-0080S) with the 

Guide Wire Handle (1806-1095 and 

1806-1096) through the talocalcaneal 

and tibiotalar joints. Reaming is then 

performed with the Bixcut Reamers 

in 0.5mm increments until cortical 

contact is made within the tibia. For 

easier nail insertion, the medullary 

canal should be reamed 0.5−1.0mm 

more than the nail diameter selected 

(Fig. 9). 

The Ball Tip at the end of the Guide 

Wire will stop the Bixcut Reamer 

(Fig. 10). 

Prior to reaming, it is important to 

check the centered intramedullary 

position of the Guide Wire with 

image intensifier. 

Prior to nail insertion, the 

Ø3×800mm Ball Tip Guide Wire 

must be exchanged for a Ø3×800mm 

Smooth Tip Guide Wire (1806- 

0090S). 

Fig 9 

Use the Teflon Tube (1806-0073S) 

to facilitate guide wire exchange. 

Fig 10 

11


Target Device Assembly 

• Pre-load the Compression Screw 

(1818-0001S). 

Use the Compression Screwdriver 

(1806-3210) to insert the 

Compression Screw into the nail (Fig. 

11a). 

Make sure the screw is set between 

the round and the oblong hole. 

Fig 11a 

Prior to nail insertion, the Ball Tip 

Guide Wire must be exchanged for a 

Smooth Tip Guide Wire. 

The pre-loaded Compression Screw is 

cannulated but does not allow the ball 

tip to pass through. 

• Assemble the Apposition Handle 

(1806-3215) onto the Nail Adapter 

(1806-3211). Turn the Apposition 

Handle until the end of the threads 

in order not to influence the insertion 

depth of the nail (Fig. 11b). 

• Attach the selected nail to the 

Nail Adapter (Fig. 11c) until it´s 3 

connection teeth engage into the 

corresponding slots of the Nail. 

The Nail Holding Screw (1806- 

3203) is placed through the Nail 

Adapter and tightened securely 

with the Insertion Wrench (1806- 

0135) and Wrench 8/10mm (1806- 

0130) to avoid loosening during 

Nail insertion. Engravings on the 

Nail Adapter will indicate lateral 

direction. 

Fig 11b 

Fig 11c 

• Insert the Target Arm (1806-3212) 

over the Nail Adapter and lock it 

in the “Lateral Locking” position. 

Attach the Aiming Adapter (1806- 

3216) and secure the whole assembly 

by tightening the Nut (1806-3213) 

(Fig. 12). 

Prior to nail insertion please check 

correct alignment of the Targeting 

Device by inserting a Ø4.2 × 340mm 

Drill (1806-4260S) through the 

assembled Tissue Protection (1806- 

0185) and Drill Sleeve, Long, (1806- 

0215) placed into the Targeting Arm 

and targeting all “Lateral Locking” 

holes of the implant. 

Note: 

If the Apposition Sleeve (1806- 

3214) is to be used, slide it 

over the nail and Nail Adapter 

prior to nail insertion. 

Note: 

The Aiming Adapter should 

be attached only when the 

Target Arm is mounted on the 

Nail Adapter in the “Lateral 

Locking” position. Check 

alignment of the P/A calcaneal 

hole by passing a K-Wire 

through the Aiming Adapter. 

Apposition 

Sleeve 

Nut 

Fig 12 

12


Nail Insertion 

Insert the nail over the Smooth Tip 

Guide Wire (Fig. 13) to the desired 

depth. 

A chamfer is located on the medial 

side of the nail driving end to 

avoid soft tissue impingement after 

insertion. 

Verify correct position of the nail 

by checking the correct depth and 

rotation. 

Depth of insertion is determined by 

CORRECT PLACEMENT OF THE 

DISTAL OBLONG HOLE IN THE 

CENTER OF THE TALAR BODY. 

This should be approximately the 

mid-talar region to ensure satisfactory 

purchase of the locking screw (Fig. 

13a). 

Two circumferential grooves are 

located on the insertion post at 2mm 

and 7mm from the driving end of the 

nail (Fig. 13b). Depth of insertion 

may be visualized with the aid of 

fluoroscopy. 

Additionally, the 3×285mm K-Wire 

can be inserted through the Targeting 

Device to identify the junction of the 

nail and insertion post (Fig. 13). 

Fig 13a 

2mm 

7mm 

Fig 13 

Rotational alignment is determined 

by a K-Wire placed into the Aiming 

Adapter. This indicates the position 

of the P/A calcaneal screw and aligns 

the screw with the anatomic calcaneal 

body axis (Fig. 14). 

Fig 13b 

Correct position is achieved when the 

K-Wire is in line with the vertical line 

marked on the plantar surface (used 

for determining the entry point) (Fig. 

14a). 

The K-Wire may be inserted 1cm 

into the calcaneus to help maintain 

position. 

Fig 14 

Remove the guide wire and proceed 

with locking screw placement. 

Fig 14a 

13


Guided Locking via Target Device 

Apposition/Compression Locking 

Mode 


provides the option to achieve active 

mechanical apposition/compression. 

Note: 

Proximal static locking with two 

Fully Threaded Locking Screws 

must be performed prior to 

applying active, controlled tibiotalar 

apposition/compression. 

Fig 15a 

Step 1: 

Guided Dynamic Locking 

of the Talar Screw 

If clinical and radiological assessment 

allow for applying tibio-talar 

compression, a 5mm Shaft Screw 

should be placed in the Dynamic 

position of the oblong hole. This 

will allow for a maximum of 5mm 

of active, controlled apposition/ 

compression. Make sure the Target 

Arm is locked in the “Lateral 

Locking” position to place the screw 

from the lateral side of the talus. 

• Insert the Tissue Protection Sleeve, 

Long, (1806-0185) together with 

the Drill Sleeve, Long, (1806-0215) 

and the Trocar, Long, (1806-0315) 

into the “Talus Dyn./Compr.” 

hole of the Targeting Arm by 

pressing the Safety Clip (Fig. 15a). 

This mechanism will keep the 

sleeve in place and prevent it from 

falling out. It will also prevent 

the sleeve from sliding during 

screw measurement. To release 

the Tissue Protection Sleeve, the 

Safety Clip must be pressed again. 

• Advance the assembly through 

the skin incision that was used 

for joint preparation until it 

is in contact with the lateral 

cortex of the Talus (Fig. 15). 

Fig 15 

14


• The Trocar is removed, with the 

Tissue Protection Sleeve and the 

Drill Sleeve remaining in position 

(Fig. 16). 

• To ensure accurate drilling and 

determination of the screw 

length, use the centered tipped 

4.2×340mm calibrated Drill 

(1806-4260S). After drilling both 

cortices, the screw length may be 

read directly from the calibrated 

Drill at the end of the Drill Sleeve 

(Fig. 16a). 

• Next, drill the near cortex only, 

with the Ø5×230mm Drill (1806- 

5000S). 

• If measurement with the Screw 

Gauge, Long, (1806- 0325) is 

preferred, first remove the Drill 

Sleeve and read the screw length 

directly at the end of the Tissue 

Protection Sleeve. 

The position of the tip of the Drill as 

it relates to the far cortex is equal to 

where the tip of the screw will end. 

Therefore, if the tip of the Drill is 

3mm beyond the far cortex, the tip of 

the screw will also be 3mm beyond. 

The Screw Gauge is calibrated so that 

when the bend at the end is pulled 

back flush with the far cortex, the 

screw tip will end 3mm beyond the 

far cortex. 

Note: 

Make sure the Tissue Protection 

Sleeve/Drill Sleeve Assembly is seated 

on bone prior to selecting final screw 

length. (according to this picture) 

Fig 16a 

Fig 17a 

Fig 16 

• Remove the Drill Sleeve and insert 

the appropriate Shaft Screw length 

through the Tissue Protection 

Sleeve using the Screwdriver, Long, 

(1806-0232) (Fig. 17). The screw is 

advanced through both cortices. 

The screw is near its proper seated 

position when the groove around 

the shaft of the screwdriver is 

approaching the end of the Tissue 

Protection Sleeve (see Fig. 17a). 

• Remove the Tissue Protection 

Sleeve and proceed with proximal 

locking. 

Note: 

The Adapter and K-Wire must 

be removed before turning the 

Target Arm to the medial side for 

proximal locking. 

15 

Fig 17


Step 2: 

Guided Locking of the 

Proximal Screws 

Note: 

Guided Locking of the Proximal 

Screws must be performed with 

the Target Arm locked in the 

“Medial Locking” position. 

Do not attempt to use the Target 

Arm in the “Lateral Locking” 

position for proximal locking as 

this will lead to miss-drilling. 

The 300mm Nails can be locked 

proximally only with the 

free-hand technique. 

• Release the Nut and turn the 

Target Arm around the Nail 

Adapter until it can be locked in 

the “Medial Locking” position 

(Fig. 18). 

Before locking the proximal screws, 

check with the image intensifier 

the gap between the tibial and talar 

surface. If this is more than 5mm, try 

to reduce the gap by applying gentle 

pressure on the Nail Adapter. 

Fig 18 

• Insert the Tissue Protection 

Sleeve, Long, together with the 

Drill Sleeve, Long, and the Trocar, 

Long, into the appropriate hole 

for locking the static proximal 

hole of the selected Nail length 

(150mm or 200mm are marked on 

the Target Arm). 

• Make a small skin incision in 

front of the Trocar and push 

the assembly until the Tissue 

Protection Sleeve is in contact with 

the medial cortex of the tibia (Fig. 

19) 

Before starting to drill for the first 

proximal locking screw, check correct 

rotational position for the fusion; an 

imaginary sagital line drawn down 

from the tibia tuberosity, along the 

tibial crest, should align with the 

second ray of the foot (Fig. 19). 

Fig 19 

16


• The Trocar is removed, with 

the Tissue Protection Sleeve 

and the Drill Sleeve remaining 

in position (Fig. 20). 

• To ensure accurate drilling, 

it is recommended to use the 

Ø4.2×250, Drill oblique (1806- 

8018) to open the first cortex. 

• Use the centered tipped 


(1806-4260S). After drilling 

both cortices, the screw length 

may be read directly from the 

calibrated Drill at the end of 

the Drill Sleeve (Fig. 20a). 

The position of the tip of the Drill, as 

it relates to the far cortex, is equal to 

where the tip of the screw will end. 

Fig 20a 

• When the Drill Sleeve is removed, 

the correct Fully Threaded 

Locking Screw is inserted through 

the Tissue Protection Sleeve using 

the Screwdriver, Long. The screw 

is advanced through both cortices. 

The screw is near its proper seating 

position when the groove around 

the shaft of the screwdriver is 

approaching the end of the Tissue 

Protection Sleeve (see Fig. 21). 

Fig 20 

The countersink (1806-2015) can be 

used through the Tissue Protection 

Sleeve to help sinking the proximal 

screw head. If this is used, undersize 

the screw length by 5mm. 

Fig 21 

17


• Repeat the locking procedure for 

the second Locking Screw 

(Fig. 22). This one can only be 

placed in the dynamic position of 

the proximal oblong hole. 

• Remove the Tissue Protection 

Sleeve and proceed with the tibiotalar 

compression. 

Step 3: 

Tibio-talar apposition/compression 

• Insert the Compression 

Screwdriver (1806-3210) through 

Nail Holding screw until the tip of 

the Screwdriver engages into the 

Compression Screw. 

• Start turning the Compression 

Screwdriver clockwise. As the 

Compression Screw is advanced 

against the 5.0mm Partially 

Threaded Locking Screw (Shaft 

Screw), it draws the talus towards 

the proximal tibial segment, 

employing active apposition/ 

compression (Fig. 23). 

Fig 22 

Note: 

Caution should be taken when 

actively compressing across 

the tibiotalar fusion site in 

osteoporotic bone to avoid 

iatrogenic talus fractures due 

to overcompression. Tibio-talar 

active compression must be 

carried out under fluoroscopy 

control. 

Before proceeding with the guided 

locking of the Lateral Calcaneal 

Screw, external talo-calcaneal 

apposition/compression can be 

applied, if needed. 

Fig 23 

18


Step 4 (optional): 

Talo-calcaneal external compression 

External compression is achieved by 

inserting the Apposition Ring (1806- 

3204) over the Apposition Handle 

(1806-3215). This will protect the soft 

tissues by applying compression forces 

on a larger surface. 

Turn the Apposition Handle 

Clockwise until the Apposition Ring 

is in contact with the soft tissues. 

Continue turning the Apposition 

Handle to apply talo-calcaneal 

apposition/compression (Fig. 24). 

Alternatively, the Apposition Sleeve 

(1806-3214) can be used to apply 

external compression directly on the 

calcaneal cortex in case of poor soft 

tissue condition. 

Fig 24 

Note: 

The Apposition Sleeve must be 

inserted over the Nail Adapter 

before nail insertion. 

Step 5: 


Lateral Calcaneal Screw 

• Release the Nut and turn the Target 

Arm around the Nail Adapter 

until it can be locked again in the 

“Lateral Locking” position (Fig. 25). 


Long, together with the Drill 

Sleeve, Long, and the Trocar, Long, 

into the “Calcaneus” hole of the 

Target Arm by pressing the Safety 

Clip. 

• Make a small skin incision in 

front of the Trocar and push 

the assembly until the Tissue 

Protection Sleeve is in contact with 

the lateral calcaneal cortex. 

• The Trocar is removed, with the 

Tissue Protection Sleeve and the 

Drill Sleeve remaining in position. 

• Use the centered tipped 


(1806-4260S). After drilling both 

cortices, the screw length may be 

read directly from the calibrated 

Drill at the end of the Drill Sleeve. 

• When the Drill Sleeve is removed, 

the correct Fully Threaded Locking 

Screw is inserted through the 

Tissue Protection Sleeve using the 

Screwdriver, Long (Fig. 26). 

Step 6: 


Posterior Calcaneal Screw 

• Release the external compression 

• Release the Nut and turn the Target 

Arm around the Nail Adapter until 

it can be locked in the “Posterior 

Locking” position. 


Sleeve, Long, together with the 

Drill Sleeve, Long, and the Trocar, 

Long, into the Calcaneus hole of 

the Targeting Arm by pressing the 

Safety Clip (Fig. 27). 

• Repeat the locking procedure as 

described for the Lateral Calcaneal 

Locking. 

The countersink (1806-2015) can be 

used through the Tissue Protection 

Sleeve to assist in sinking the P/A 

Calcaneus screw head. If this is used, 

undersize the screw length by 5mm. 

19 

Fig 25 

Fig 26 

Fig 27


Static Locking Mode 

Step 1: 

Guided Static Locking of the 

Talar Screw 

If clinical and radiological 

assessment does not allow for 

applying tibio-talar compression, a 

5mm Shaft Screw should be placed 

in the Static position of the oblong 

hole. Make sure the Target Arm 

is locked in the “Lateral Locking” 

position to place the screw from 

the lateral side of the talus. 


Sleeve, Long, together with 

the Drill Sleeve, Long, and the 

Trocar, Long, into the “Talus 

Static” hole of the Target Arm by 

pressing the Safety Clip (Fig. 28). 

• Follow the same locking 

procedure as described on page 

14 and 15 for the insertion of the 

Talar Screw in dynamic position. 

Fig 28 

20


• After the Talar Screw is inserted, 

remove the Tissue Protection 

Sleeve and proceed with advancing 

the compression screw against 

the Talar Screw (Fig. 29). 

• Insert the Compression 

Screwdriver (1806-3210) through 

Nail Holding screw until the 

tip of the Screwdriver engages 

into the Compression Screw. 

• Start turning the Compression 

Screwdriver clockwise. The 

Compression Screw will advance 

until it locks down onto the 

Talar Screw providing axial 

stability of the construct. 

Caution: 

The coupling of Elastosil Handles 

contains a mechanism with 

one or multiple ball bearings. 

In case of applied axial stress 

on the Elastosil handle, those 

components are pressed into the 

surrounding cylinder resulting in 

a complete blockage of the device 

and possible bending. To avoid 

intra-operative complications and 

secure long-term functionality, we 

mandate that Elastosil handles be 

used only for their intended use. 

DO NOT HIT hit on them. 

Fig 29 

Step 2: 


Lateral Calcaneal Screw 

• After locking the Talar screw 

in place with the compression 

screw, leave the Target Arm in 

the “Lateral Locking” position 

and proceed with the Lateral 

Calcaneal screw insertion. 

• Follow the locking procedure 

as described on page 19 for the 

Lateral Calcaneal Screw. 

Fig 30 

21


Step 3: 


Proximal Screws 

Note: 

Guided Locking of the Proximal 

Screws must be performed with 

the Target Arm locked in the 

“Medial Locking” position (Fig. 

30). 

The 300mm Nails can be locked 

proximally only with the freehand 

technique. 

• Proceed with the locking 

procedure as described on page 

16 and 17 for the Apposition/ 

Compression Locking Mode. 

Fig 31 

Step 4: 


Posterior Calcaneal Screw 

• Release the Nut and turn the 

Target Arm around the Nail 

Adapter until it can be locked in 

the “Posterior Locking” position 

(Fig. 32). 


Long, together with the Drill 

Sleeve, Long, and the Trocar, Long, 

into the Calcaneus hole of the 

Target Arm by pressing the Safety 

Clip. 

• Repeat the locking procedure as 

described on page 19. 

Fig 32 

22


Freehand Proximal Locking of Long Nails 

The freehand technique is used to 

insert locking screws into both M/L 

proximal holes of the T2 Ankle 

Arthrodesis Long Nails (300mm). 

Multiple locking techniques and 

radiolucent drill devices are available 

for freehand locking. The critical 

step with any freehand locking 

technique, proximal or distal, 

is to visualize a perfectly round 

locking hole or perfecty oblong 

locking hole with the C-Arm. 

• Hold the center-tipped 

Ø4.2×130mm Drill (1806-4280) 

at an oblique angle to the center 

of the locking hole (Fig. 33). 

Upon fluoroscopic verification, 

the Drill is placed perpendicular 

to the nail and drilled through 

the medial and lateral cortex 

of the tibia. Confirm that the 

Drill passes through the hole 

in the nail in both the A/P 

and M/L fluoroscopy views. 

• After drilling both cortices, 

the screw length may be read 

directly from Screw Scale, 

Short, (1806-0360) at the green 

ring on the center-tipped 

Ø4.2×130mm Drill(Fig. 34). 

Alternatively, the Screw Gauge 

(1806-0480) can be used 

instead of the Screw Scale to 

determine the screw length. 

• Routine locking screw 

insertion is employed with the 

assembled Screwdriver Shaft, 

Short, (1806-0294) and the 

Teardrop Handle (702429). 

• Repeat the locking procedure 

to insert the second 

proximal locking screw. 

Fig 33 

Fig 34 

23


End Cap Insertion 

The End Cap (1826-0003S) can be 

inserted 

• Either through the Nail Adapter, 

with the Screwdriver, Long, (after 

removal of the Nail Holding Screw) 

or 

• With the Screwdriver Shaft, Short, 

and the Teardrop Handle (Fig. 35), 

after removal of the Target Device 

(Fig. 35). 

Note: 

This is the same End Cap used 

for the T2 SCN. The End Cap will 

lock on the distal P/A calcaneal 

screw providing additional axial 

stability. 

Fig 35 

Extension End Caps of +5, +10 and 

+15mm are also available to adjust 

nail length and lock down on the 

distal P/A calcaneal screw. These End 

Caps cannot be inserted through 

the Nail Adapter due to the larger 

diameter of the head. 

Extension End Caps are not 

cannulated. 

+5mm +10mm +15mm 

24


Nail Removal 

Nail removal is an elective procedure. 

• If used, remove first the End Cap 

and the most distal Screw with the 

Screwdriver, Long (Fig. 36). 

• Remove the Lateral Calcaneal 

Screw. 

• Release the Compression Screw to 

allow removal of the Talar screw. 

• Insert the Universal Rod into the 

driving end of the nail. 

• Remove all other Locking Screws 

and use the Slottet Hammer 

(1806-0170) to extract the nail in a 

controlled manner (Fig. 37). 

Fig 36 

Fig 37 

25


Case Reports 

Provided by Anthony T. Sorkin, M.D. 

The patient is a 58 year old male 

with a pilon fracture 30 years 

prior to her first visit to the 

office, complaining of severe 

pain. Advanced post-traumatic 

arthritis of both sub-talar and 

tibio-talar joints can be seen on the 

preoperative X-Rays (Fig. 38 and 

Fig. 39). 

Incisions were made both laterally 

and medially to fully debride the 

tibiotalar and subtalar joints. 


used as definitive treatment. 

Tibio-talar compression was 

applied with a preloaded 

compression screw. Additional 

talo-calcaneal compression 

was achieved with the external 

compression device. Axially 

stable locking of the transverse 

calcaneal screw (passing through 

a threaded hole of the T2 

AAN) and P/A calcaneal screw 

(locked in place by the end cap) 

providing increased stability. 

Postoperative X-Rays (Fig. 

40a, 40b, 40c) show perfect 

alignment sustained by the 

5° valgus of the T2 AAN. 

Patient weight bearing at 8 weeks without any pain. 

Fig 38 

Fig 39 

Fig 40a 

Fig 40b 

Fig 40c 

26

References 

1. Tibiotalocalcaneal fusion with a retrograde intramedullary nail: 

clinical and functional outcomes. 

Millett PJ, O‘Malley MJ, Tolo ET, Gallina J, Fealy S, Helfet DL. 

Harvard Medical School, Brigham & Women‘s Hospital, Boston, 

Massachusetts, USA. Am J Orthop. 2002 Sep; 31(9):531-6. 

2. The effect of bone quality on the stability of ankle arthrodesis. 

A finite element study. 

Alonso-Vazquez A, Lauge-Pedersen H, Lidgren L, Taylor M. 

Bioengineering Sciences Research Group, School of Engineering Sciences, 

University of Southampton, Southampton SO17 1BJ, UK. Foot Ankle Int. 

2004 Nov; 25(11):840-50. 

3. Ankle arthrodesis with intramedullary compression nailing 

Muckley T, Schutz T, Srivastava S, Goebel M, Gonschorek O, Bühren V. 

Berufsgenossenschaftliche Unfallklinik, Murnau. Unfallchirurg. 

2003 Sep; 106(9):732-40. 

4. Realignment arthrodesis of the rearfoot and ankle: 

a comprehensive evaluation. 

Mendicino RW, Lamm BM, Catanzariti AR, Statler TK, Paley D. 

Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, 

Pittsburgh, PA 15224, USA. 

5. Primary stiffness of different arthrodesis techniques for the upper ankle 

joint considering the compression nail: a biomechanical study 

Muckley T, Eichhorn S, Steinhauser E, von Oldenburg G, Speitling A, 

Hofmann G.O., J. Ortop. Trauma 2004 #18, 

6. Intramedullary nailing in tibiocalcaneal arthrodesis 

Goebel M, Muckley T, Gerdesmeyer L, Militz M, Bühren V. 

Unfallchirurg. 2003 Aug; 106(8):633-41 

27

Ordering Information – Implants 

Ankle Arthrodesis Nail, left 

REF Diameter Length 

mm 

mm 

1818-1015S 10 150 

1818-1020S 10 200 

1818-1030S 10 300 

1818-1115S 11 150 

1818-1120S 11 200 

1818-1130S 11 300 

1818-1215S 12 150 

1818-1220S 12 200 

1818-1230S 12 300 

Ankle Arthrodesis Nail, right 


mm 

mm 

1819-1015S 10 150 

1819-1020S 10 200 

1819-1030S 10 300 

1819-1115S 11 150 

1819-1120S 11 200 

1819-1130S 11 300 

1819-1215S 12 150 

1819-1220S 12 200 

1819-1230S 12 300 

Compression Screw (cannulated) 


mm 

mm 

1818-0001S 8.0 14.5 

End Caps 


mm 

mm 

1826-0003S 8.0 4.0 

1818-0005S 12.0 +5mm 

1818-0010S 12.0 +10mm 

1818-0015S 12.0 +15mm 

+5mm 

+10mm 

+15mm 

28

Ordering Information – Instruments 

REF 

Description 

Standard Instruments 

1806-3217 T2 AAN X-Ray Template 

1806-0050 K-Wire 3×285mm (2) 

703165 Protection Sleeve Retrograde 

1806-0073S Teflon Tube, sterile 

1806-0080S Guide Wire, Ball Tip, Ø3×800mm, Sterile 

1806-0090S Guide Wire, Smooth Tip, Ø3×800mm, Sterile 

1806-1095 Guide Wire Handle 

1806-1096 Guide Wire Handle Chuck 

1806-0110 Universal Rod 

1806-0130 Wrench, 8mm / 10mm 

1806-0135 Insertion Wrench, 10mm 

1806-0150 Strike Plate 

1806-0170 Slotted Hammer 

1806-0185 Tissue Protection Sleeve, Long 

1806-0215 Drill Sleeve, Long 

1806-0232 Screwdriver, Long 

1806-0294 Screwdriver Shaft, 3,5×85 mm, conical tip 

702429 Teardrop Handle 

1806-0315 Trocar, Long 

1806-0325 Screw Gauge, Long 

1806-0360 Screw scale short (only for 300mm nails) 

1806-0480 Screw Gauge, Femur (only for 300mm nails) 

1806-2013 Stepped Reamer, Ø8/12mm 

1806-2015 Countersink 

29

Ordering Information – Instruments 

REF 

Description 

Standard Instruments 

1806-3213 Nut, T2 AAN 

1806-3218 Nut Tightening Pin 

1806-3211 Nail Adapter 

1806-3212 Targeting Arm 

1806-3203 Nail Holding Screw 

1806-3204 Apposition-ring 

1806-3214 Apposition Sleeve 

1806-3215 Apposition-handle 

1806-3216 Aiming Adapter 

1806-3210 Compression Screwdriver 

1806-4260S Drill Ø4.2×340mm, AO, Sterile (2) 

1806-4280S Drill Ø4.2×130mm, Sterile (2) (only for 300mm nails) 

1806-5000S Drill Ø5×230mm, AO, Sterile (2) 

1806-8018 Drill oblique, Ø4.2×250mm 

1806-9263 T2 AAN Dedicated Instrument Tray 

1806-9265 T2 AAN Add-on Instrument Tray 

30 

Note: 

Outside of the U. S., Locking 

Screws and other specific 

products may be ordered nonsterile 

without the “S” at the end 

of the corresponding Reference 

Number.

Notes 

31

Stryker Trauma GmbH 

Prof.-Küntscher-Straße 1–5 

D - 24232 Schönkirchen 

Germany 

www.osteosynthesis.stryker.com 

This document is intended solely for the use of healthcare professionals. A surgeon must always rely on his or her own 

professional clinical judgment when deciding whether to use a particular product when treating a particular patient. 

Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product 

before using it in surgery. The information presented in this brochure is intended to demonstrate a Stryker product. 

Always refer to the package insert, product label and/or user instructions including the instructions for Cleaning and 

Sterilization (if applicable) before using any Stryker products. Products may not be available in all markets. Product 

availability is subject to the regulatory or medical practices that govern individual markets. Please contact your Stryker 

representative if you have questions about the availability of Stryker products in your area. 

Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following 

trademarks or service marks: Stryker, T2, Elastosil, Bixcut. 

All other trademarks are trademarks of their respective owners or holders. 

The products listed above are CE marked. 

Literature Number: B1000044 

LOT C3009 

Copyright © 2009 Stryker

T2 Ankle Arthrodesis Nail - Stryker

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